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4PPLICATION FOR WELLIPUMP PERMI- SAK--JAQUIN COUNTY PUBLIC HEALTH SE6wiCES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 (C V NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v (Complob In TrlpIketal At"ICAT10N IS IIFRE BY MADE TO TIIE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL 714E WOW DESCRIBED.T111/APPLICATION IS MADE IN COMMIANCE Wl/ll BAN JOAOUIN COUNTY DEVELOPMENT TILE.CHAPTER 8-1 115.3 AND TIIE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC IIEALTIt SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/On APNF 1044 M a d r u R a Rd . CITY Lathrop PARCEL SIZEIAPNF OWI7En•SNAMf St Helena Construction ADDRESS 2601 Silverado TrailMIONE x707-963-8058 CON7RACTOR F r P ; t a s F. 1 e c t r i c / T n r ADDRESS P . O . B x 16 Banta uc. 4 5 3 9 6 2 MtoNE.8 3 5-2 8 14 OUR CONTRACTOR ADDRESS LOCO MIONF I TYPE OF WELLIPVMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ C11088-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ � _ ❑New 1cl .1, II.P. I _ DEPTH PUMP SET FT. 0 FIRST WATER LEVEL 1 8 IT YPE OF M)MPI ❑ Ol7T-OF-SERVICE WELL ❑ GEOMIYSICAL WELLI ❑ BOIL BORING 8 ❑OFSTRUCTION: INTENDED Uhf TYPE OF WELL CONSTRUC110N SPECIFICATIONS A ❑ INMI87RIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOn CASINO __ n ❑ DOMEAIMIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASWOIBTEEll1'VC DIA.OF WELL CASINO D ❑ M/BLIC/MONICIPAL ❑OIIIvFN DEPTH OF GROUT BEALSPECIrICATION q ❑ MR1OA710NIAO ❑OTHER GROUT SEAL INSTALLED BY :ROUT BRAND NAME E ❑ MONITOISNG GROUT BEAL PUMPED: ❑Yw ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yw []No S APPROX.DEPTH 6 7 LOCKING CHEBTEn BOX18TOVE PIPE t PROPOSFD CONS TRUC T10NA MtUNG METHOo: MUD ROTARY AIR ROTARY AUGER CABLE OTHER- 1 IIE9ERY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND 7HAT TIIE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND n1AES AND RFOl1LATION8 OF THE SAN JOAQUIN COVNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES 714E FOLLOWING:'1 CERTIFY THAT IN TIIE PERFORMANCE OF TIIE WORK Fon WIIICII 71418 PFnMIT 18 ISSUED,1 SHALL NOT EMPLOY Pfn9ON8 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES 711E FOLIOWINO! '1 C THAT IN TIIE PERFORMANCE OF THE WORK FOR WHICH 71418 PERMIT SB ISSUED,I SHALL EMPLOY PfnSONB SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAtIFO NFA ANT UST CALL 24 TIO IN ADVANCE FOR ALL REOUIR[D IN ► T10N1 AT I2�MT 4883422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Blenwd X TIUe �+- - bete•�.•c—�� PLOT FLAN(INew to&.1.1 Rp•Is 'to 1. NAMFA OF STREETS OR ROADS NEAREST 70 On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On Pito Po SEB 2. OITLINE OF 711E PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMFNSIONEO OUTUNF,S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE IIVNOnFO rIr7Y FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 1 �o X11 y : 4. . .. . - PAYMENT . t i.. A .. E SAN;,IA/�ULIIN CQlJN7Y .. f NV RGNME PUBLIC .. . : HEALTH SERVICES . .•. .•..VITAL HEALTH pIV191CTt•�; .,• DEPARTMENT US!ONLY �•/F Applle•tlnn Aeawpttwl Ry bele Arw V+ Grout I—P-Oen By Date P-P Impeellen By Data D,.•btw;tlen Imp--len 11 Date CernmerN•• ACCOUNTING ONLY: AID,I FACA' PE CODES FEE tNFO AMOUNT REMITTED11C.IEC CAAII RECEIVED By DATE PEnMITISERVICE REQUEST NUMBM INVOICE 3�3q g�'ra o A: 3 Pub.Health Serv.-Enviro.173(1/97)